ls -la /home/daytona/workspace/ && ls /home/daytona/skills/docx/

mkdir -p /home/daytona/workspace/copd-assignment && ls /home/daytona/skills/docx…

~/copd-assignment/create_copd.js

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// ─── helpers ────────────────────────────────────────────────────────────────

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// ─── COVER PAGE ─────────────────────────────────────────────────────────────

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// ─── CONTENT ────────────────────────────────────────────────────────────────

const content = [

  // ── 1. INTRODUCTION ──────────────────────────────────────────────────────
  heading1('1. INTRODUCTION'),
  bullet('COPD (Chronic Obstructive Pulmonary Disease) is a chronic, progressive lung disease that causes airflow obstruction and breathing difficulty.'),
  bullet('It is one of the leading causes of morbidity and mortality worldwide; ranked as the 3rd most common cause of death globally (WHO, 2023).'),
  bullet('COPD mainly includes two conditions: Chronic Bronchitis and Emphysema, which often coexist in the same patient.'),
  bullet('The disease is largely preventable — cigarette smoking is responsible for 85-90% of all COPD cases.'),
  bullet('Early diagnosis and proper nursing management can slow disease progression, reduce exacerbations, and greatly improve quality of life.'),
  spacer(),

  // ── 2. DEFINITION ────────────────────────────────────────────────────────
  heading1('2. DEFINITION'),
  para('COPD is a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation, caused by airway and/or alveolar abnormalities, usually due to significant exposure to noxious particles or gases (primarily cigarette smoke).'),
  new Paragraph({
    children: [
      new TextRun({ text: '  - Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2023', italics: true, size: 20 }),
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    spacing: { after: 60 },
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  para('Chronic Bronchitis: Persistent productive cough for at least 3 consecutive months in 2 or more consecutive years.'),
  para('Emphysema: Permanent enlargement and destruction of air spaces distal to the terminal bronchioles, with loss of elastic recoil.'),
  spacer(),

  // ── 3. ANATOMY & PHYSIOLOGY ───────────────────────────────────────────────
  heading1('3. ANATOMY & PHYSIOLOGY (Related to COPD)'),

  heading2('A. Normal Anatomy of the Respiratory System'),
  bullet('Airways: Nose → Pharynx → Larynx → Trachea → Bronchi → Bronchioles → Alveoli'),
  bullet('Lungs: Two lungs (right = 3 lobes, left = 2 lobes) covered by pleura'),
  bullet('Alveoli: Tiny air sacs where gas exchange (O2/CO2) takes place; walls are thin and elastic'),
  bullet('Diaphragm: Main muscle of breathing; contracts during inspiration'),
  bullet('Goblet cells: Produce mucus to trap particles in airways'),
  bullet('Cilia: Hair-like structures that move mucus up and out of airways (mucociliary escalator)'),

  heading2('B. Normal Physiology'),
  bullet('Ventilation: Air moves in and out of lungs (tidal volume = 500 mL normally)'),
  bullet('FEV1 (Forced Expiratory Volume in 1 second): Normal = >80% predicted'),
  bullet('FVC (Forced Vital Capacity): Volume of air forcefully expelled after deep breath'),
  bullet('FEV1/FVC ratio: Normal = >0.70 (70%); In COPD = <0.70 (obstructed)'),
  bullet('Oxygen: PaO2 normal = 80-100 mmHg; CO2: PaCO2 normal = 35-45 mmHg'),
  bullet('Gas exchange: O2 diffuses into blood; CO2 diffuses out at alveolar-capillary membrane'),

  heading2('C. Changes in COPD'),
  bullet('Cigarette smoke/pollutants → Airway inflammation → Goblet cell hyperplasia → Excess mucus production'),
  bullet('Destruction of alveolar walls → Loss of elastic recoil → Air trapping → Barrel chest'),
  bullet('Airway narrowing → Increased resistance → Reduced airflow (↓ FEV1)'),
  bullet('V/Q mismatch (ventilation-perfusion mismatch) → Hypoxemia (low O2) + Hypercapnia (high CO2)'),
  bullet('Progressive changes lead to cor pulmonale (right-sided heart failure) in advanced stages'),
  spacer(),

  // ── 4. ETIOLOGY / CAUSES ─────────────────────────────────────────────────
  heading1('4. ETIOLOGY / CAUSES'),

  heading2('A. Modifiable Risk Factors (Can be changed)'),
  numbered('Cigarette Smoking – Most important cause; responsible for 85-90% of COPD cases'),
  numbered('Second-hand / Passive Smoking'),
  numbered('Occupational Exposure – Coal dust, silica, cadmium, grain dust'),
  numbered('Indoor Air Pollution – Biomass fuel smoke (wood, cow dung) from cooking in poorly ventilated homes'),
  numbered('Outdoor Air Pollution – Vehicle exhaust, industrial pollutants'),
  numbered('Recurrent Respiratory Infections – Especially in childhood'),
  numbered('Poorly controlled asthma'),
  spacer(),

  heading2('B. Non-Modifiable Risk Factors (Cannot be changed)'),
  numbered('Genetic factors – Alpha-1 antitrypsin (AAT) deficiency (panacinar emphysema)'),
  numbered('Age – Risk increases with age (usually >40 years)'),
  numbered('Gender – More common in males; but rising incidence in females'),
  numbered('Low socioeconomic status'),
  numbered('Premature birth / low birth weight – Affects lung development'),
  numbered('Airway hyperresponsiveness'),
  spacer(),

  // ── 5. PATHOPHYSIOLOGY ──────────────────────────────────────────────────
  heading1('5. PATHOPHYSIOLOGY'),
  bold('(Flowchart Format)'),
  spacer(),
  para('Exposure to cigarette smoke / noxious particles'),
  para('          ↓'),
  para('Airway inflammation (neutrophils, macrophages release proteases)'),
  para('          ↓'),
  para('        ┌─────────────────────────────┐'),
  para('        │                             │'),
  para('   In Large Airways             In Small Airways / Alveoli'),
  para('Goblet cell hyperplasia      Alveolar wall destruction'),
  para('Mucus hypersecretion         Loss of elastic recoil'),
  para('Chronic bronchitis           Emphysema'),
  para('        │                             │'),
  para('        └──────────────┬──────────────┘'),
  para('                       ↓'),
  para('           Airway obstruction (FEV1/FVC < 0.70)'),
  para('                       ↓'),
  para('     V/Q mismatch → Hypoxemia (PaO2 < 60 mmHg)'),
  para('                       ↓'),
  para('     Hypercapnia (PaCO2 > 45 mmHg) + Respiratory acidosis'),
  para('                       ↓'),
  para('Pulmonary hypertension → Cor pulmonale → Right Heart Failure'),
  spacer(),

  // ── 6. SIGNS & SYMPTOMS ──────────────────────────────────────────────────
  heading1('6. SIGNS & SYMPTOMS'),

  heading2('A. Early Symptoms'),
  bullet('Chronic productive cough (especially in the morning)'),
  bullet('Increased sputum production (white or clear)'),
  bullet('Mild dyspnea (shortness of breath) on exertion'),
  bullet('Frequent respiratory infections (colds, bronchitis)'),
  bullet('Mild wheezing'),
  bullet('Reduced exercise tolerance / easy fatigue'),

  heading2('B. Late Symptoms'),
  bullet('Severe dyspnea at rest (cannot speak in full sentences)'),
  bullet('Barrel chest (A-P diameter increased due to air trapping)'),
  bullet('Pursed-lip breathing (patient exhales slowly through pursed lips)'),
  bullet('Use of accessory muscles (sternocleidomastoid, intercostal) for breathing'),
  bullet('Cyanosis (bluish discoloration of lips and fingertips) – "Blue Bloater" in bronchitis type'),
  bullet('Pink puffer appearance (thin, pink, pursed-lip breathing) – emphysema type'),
  bullet('Digital clubbing (chronic hypoxia)'),
  bullet('Cor pulmonale: JVD, pedal edema, hepatomegaly'),
  bullet('Weight loss and muscle wasting'),
  bullet('Polycythemia (↑ RBCs as compensatory response to chronic hypoxia)'),
  spacer(),

  // ── 7. DIAGNOSTIC INVESTIGATIONS ────────────────────────────────────────
  heading1('7. DIAGNOSTIC INVESTIGATIONS'),
  spacer(),
  makeTable(
    ['Test', 'Normal Value', 'Abnormal Finding in COPD'],
    [
      ['Spirometry: FEV1/FVC ratio', '> 0.70 (70%)', '< 0.70 (Airflow obstruction confirmed)'],
      ['FEV1 (% predicted)', '> 80%', 'Mild: 50-80%; Moderate: 30-50%; Severe: <30%'],
      ['Arterial Blood Gas (ABG): PaO2', '80-100 mmHg', '< 60 mmHg (Hypoxemia)'],
      ['ABG: PaCO2', '35-45 mmHg', '> 45 mmHg (Hypercapnia in severe COPD)'],
      ['ABG: pH', '7.35-7.45', '< 7.35 (Respiratory acidosis)'],
      ['ABG: HCO3-', '22-26 mEq/L', '> 26 mEq/L (Compensatory metabolic alkalosis)'],
      ['SpO2 (Pulse Oximetry)', '95-100%', '< 90% (Requires supplemental oxygen)'],
      ['Chest X-Ray (CXR)', 'Normal lung fields', 'Hyperinflation, flat diaphragm, barrel chest, bullae'],
      ['CT Scan Chest (HRCT)', 'Normal lung parenchyma', 'Air trapping, bullae, emphysema, airway wall thickening'],
      ['CBC: RBC / Hematocrit', 'RBC: 4.5-5.5 million/µL', 'Elevated (Polycythemia from chronic hypoxia)'],
      ['Sputum Culture & Sensitivity', 'No pathogens', 'H. influenzae, Pseudomonas, Streptococcus pneumoniae'],
      ['Alpha-1 Antitrypsin level', '> 80 mg/dL', 'Low in AAT deficiency (< 11 µmol/L)'],
      ['ECG / Echo', 'Normal', 'P pulmonale, RVH, signs of cor pulmonale'],
      ['6-Minute Walk Test (6MWT)', '> 400 meters', 'Reduced (exercise intolerance)'],
    ],
    [2100, 1800, 5100]
  ),
  spacer(),

  // ── 8. MEDICAL MANAGEMENT ────────────────────────────────────────────────
  heading1('8. MEDICAL MANAGEMENT'),

  heading2('A. Pharmacological Management (Drug Table)'),
  spacer(),
  makeTable(
    ['Drug', 'Dose', 'Route', 'Action', 'Side Effect'],
    [
      ['Salbutamol (Albuterol)\nSABA', '2.5 mg / 2 puffs (100 mcg/puff)', 'Inhaler / Nebulizer', 'Short-acting Beta2 agonist; bronchodilator; relieves acute dyspnea', 'Tremors, tachycardia, hypokalemia'],
      ['Ipratropium Bromide\nSAMA', '0.5 mg 4-6 hourly / 2 puffs', 'Inhaler / Nebulizer', 'Short-acting anticholinergic; reduces mucus secretion; bronchodilator', 'Dry mouth, urinary retention, blurred vision'],
      ['Tiotropium\nLAMA', '18 mcg once daily', 'Dry powder inhaler', 'Long-acting anticholinergic; maintains airway dilation 24 hours', 'Dry mouth, constipation, sinusitis'],
      ['Salmeterol / Formoterol\nLABA', '50 mcg BD (Salmeterol)', 'Inhaler', 'Long-acting Beta2 agonist; sustained bronchodilation', 'Tremors, palpitations, hypokalemia'],
      ['Budesonide / Fluticasone\n(ICS)', '200-400 mcg BD', 'Inhaler', 'Inhaled corticosteroid; reduces airway inflammation; used in severe COPD with frequent exacerbations', 'Oral candidiasis, dysphonia, osteoporosis (long term)'],
      ['Roflumilast\n(PDE-4 inhibitor)', '500 mcg once daily', 'Oral (tablet)', 'Reduces airway inflammation; decreases exacerbation frequency in severe COPD with chronic bronchitis', 'Nausea, diarrhea, weight loss, depression'],
      ['Prednisolone\n(Systemic steroid)', '30-40 mg OD x 5-7 days', 'Oral / IV', 'Used in acute exacerbations; reduces severe inflammation', 'Hyperglycemia, immunosuppression, peptic ulcer'],
      ['Theophylline', '200-400 mg BD (slow release)', 'Oral', 'Methylxanthine; bronchodilator + respiratory muscle stimulant (adjunct)', 'Nausea, arrhythmias, seizures (narrow therapeutic window)'],
      ['Amoxicillin-Clavulanate\n/ Azithromycin\n/ Doxycycline', 'As per sensitivity', 'Oral / IV', 'Antibiotic for bacterial exacerbations (H. influenzae, S. pneumoniae)', 'GI upset, C. diff risk, hepatotoxicity (azithromycin)'],
      ['Mucolytics (Carbocisteine / NAC)', '375-750 mg BD', 'Oral', 'Reduces mucus viscosity; improves airway clearance', 'Nausea, GI irritation'],
      ['N-Acetylcysteine (NAC)', '600 mg OD', 'Oral', 'Antioxidant; mucolytic; may reduce exacerbation frequency', 'GI upset, bronchospasm if inhaled'],
    ],
    [1500, 1200, 1000, 2700, 2600]
  ),
  spacer(),

  heading2('B. Oxygen Therapy'),
  bullet('Controlled O2 therapy: 1-2 L/min via nasal cannula (target SpO2 = 88-92% in COPD to avoid hypercapnia)'),
  bullet('Long-Term Oxygen Therapy (LTOT): > 15 hours/day for patients with PaO2 < 55 mmHg at rest'),
  bullet('Venturi mask: Delivers precise FiO2 (24%, 28%, 35%, 40%) – preferred in COPD'),
  bullet('High-flow nasal oxygen (HFNO) for severe exacerbations'),

  heading2('C. Non-Invasive Ventilation (NIV)'),
  bullet('BiPAP (Bilevel Positive Airway Pressure): Used in acute exacerbations with hypercapnic respiratory failure'),
  bullet('CPAP for nocturnal use if obstructive sleep apnea coexists'),

  heading2('D. Surgical / Interventional Management'),
  bullet('Lung Volume Reduction Surgery (LVRS): Removes hyperinflated lung tissue in severe emphysema'),
  bullet('Bullectomy: Removal of large bullae compressing normal lung tissue'),
  bullet('Lung Transplant: For end-stage COPD (FEV1 < 20%)'),
  bullet('Bronchoscopic lung volume reduction (endobronchial valves)'),
  spacer(),

  // ── 9. NURSING MANAGEMENT ─────────────────────────────────────────────────
  heading1('9. NURSING MANAGEMENT'),

  heading2('A. Nursing Assessment'),

  heading3('i. Subjective Data (What patient reports)'),
  bullet('Chief complaint: "I cannot breathe properly," "I feel breathless all the time"'),
  bullet('History of smoking (pack-years = packs/day × years smoked)'),
  bullet('Chronic cough – duration, frequency, character (productive/dry)'),
  bullet('Sputum – color, amount, consistency (white, yellow, green = infection)'),
  bullet('Dyspnea scale: How much effort triggers breathlessness (MRC Scale 0-4)'),
  bullet('History of previous exacerbations, hospitalizations'),
  bullet('Occupational history – dust, chemical exposure'),
  bullet('Medication history – inhalers used, compliance'),
  bullet('Associated symptoms: ankle swelling, fatigue, weight loss'),
  bullet('Functional limitations: activities of daily living (ADL) affected'),

  heading3('ii. Objective Data (What nurse observes/measures)'),
  bullet('Vital Signs: Tachycardia (HR > 100), tachypnea (RR > 20), low SpO2 (< 90%)'),
  bullet('Respiratory assessment: Barrel chest, use of accessory muscles, pursed-lip breathing'),
  bullet('Auscultation: Decreased breath sounds, wheezes, rhonchi, prolonged expiration'),
  bullet('Percussion: Hyperresonance (air trapping)'),
  bullet('Cyanosis: Peripheral (fingertips) or central (lips)'),
  bullet('Digital clubbing, pedal edema (cor pulmonale)'),
  bullet('ABG values: Hypoxemia, hypercapnia, respiratory acidosis'),
  bullet('Spirometry: FEV1/FVC < 0.70'),
  bullet('Chest X-Ray: Hyperinflated lungs, flattened diaphragm'),
  bullet('Nutritional status: Weight loss, muscle wasting (COPD increases caloric demand)'),
  bullet('Anxiety, restlessness (signs of hypoxia or CO2 retention)'),
  spacer(),

  heading2('B. Nursing Diagnoses (NANDA Format)'),
  spacer(),
  numbered('Ineffective airway clearance  Related to:  Excessive mucus production, airway inflammation, ciliary dysfunction  As evidenced by:  Productive cough, abnormal breath sounds (rhonchi/wheezes), dyspnea'),
  spacer(),
  numbered('Impaired gas exchange  Related to:  Destruction of alveolar walls, V/Q mismatch, alveolar hypoventilation  As evidenced by:  PaO2 < 60 mmHg, SpO2 < 90%, PaCO2 > 45 mmHg, confusion/restlessness'),
  spacer(),
  numbered('Ineffective breathing pattern  Related to:  Air trapping, hyperinflation, respiratory muscle fatigue  As evidenced by:  Use of accessory muscles, barrel chest, pursed-lip breathing, RR > 24/min'),
  spacer(),
  numbered('Activity intolerance  Related to:  Imbalance between O2 supply and demand, fatigue, dyspnea on exertion  As evidenced by:  Patient reports fatigue and dyspnea with minimal activity, reduced 6MWT distance'),
  spacer(),
  numbered('Anxiety  Related to:  Difficulty breathing, fear of suffocation, uncertainty about disease progression  As evidenced by:  Patient reports feeling scared, restless, increased respiratory rate during anxiety episodes'),
  spacer(),

  heading2('C. Nursing Care Plan (NCP)'),
  spacer(),
  makeTable(
    ['Nursing Diagnosis', 'Goal / Expected Outcome', 'Nursing Interventions', 'Rationale', 'Evaluation'],
    [
      [
        'Ineffective Airway Clearance R/T excessive mucus production AEB productive cough and abnormal breath sounds',
        'Patient will maintain clear airways as evidenced by:\n- Effective cough\n- Clear breath sounds\n- SpO2 > 90% within 24 hrs',
        '1. Assess breath sounds every 2-4 hrs\n2. Position patient in high Fowler\'s / semi-Fowler\'s (45-60°)\n3. Encourage deep breathing and effective coughing q2h\n4. Teach and assist with Huff coughing technique\n5. Administer nebulization as ordered (Salbutamol + Ipratropium)\n6. Perform chest physiotherapy (percussion and postural drainage)\n7. Ensure fluid intake 2-3 L/day (if not restricted)\n8. Administer mucolytics as prescribed\n9. Suction if patient unable to clear secretions',
        '1. Detects changes in airway status\n2. Gravity aids lung expansion; reduces pressure on diaphragm\n3. Mobilizes secretions for expectoration\n4. Huff coughing is less fatiguing and effective in COPD\n5. Bronchodilators relieve bronchospasm; open airways\n6. Loosens and mobilizes tenacious secretions\n7. Hydration thins mucus, easing clearance\n8. Reduces mucus viscosity\n9. Maintains patent airway when cough ineffective',
        'Patient demonstrates effective cough;\nBreath sounds clearer;\nSpO2 improved to > 90%;\nSputum expectoration improved'
      ],
      [
        'Impaired Gas Exchange R/T alveolar wall destruction and V/Q mismatch AEB PaO2 < 60 mmHg, SpO2 < 90%, restlessness',
        'Patient will demonstrate:\n- SpO2 88-92%\n- ABG values trending to normal\n- Alert and oriented\n- No cyanosis within 24-48 hrs',
        '1. Monitor ABG values and SpO2 continuously\n2. Administer controlled O2 via Venturi mask (24-28%); target SpO2 88-92%\n3. Avoid high-flow O2 (risk of CO2 retention and hypercapnic drive suppression)\n4. Position: Elevate HOB 30-45°; encourage tripod position\n5. Assess for signs of CO2 narcosis: confusion, drowsiness, asterixis\n6. Prepare for NIV/BiPAP if PaCO2 rising or pH < 7.35\n7. Monitor and document level of consciousness (LOC)\n8. Administer bronchodilators and steroids as ordered',
        '1. Detects worsening hypoxemia or hypercapnia early\n2. Controlled O2 prevents hypoxic drive suppression in COPD patients\n3. High O2 can blunt respiratory drive in CO2 retainers\n4. Improves diaphragmatic excursion; maximizes ventilation\n5. CO2 narcosis is a life-threatening complication of COPD\n6. NIV reduces work of breathing; prevents intubation\n7. Changes in LOC indicate hypoxia/hypercapnia progression\n8. Reduce inflammation and bronchoconstriction',
        'ABG values stabilizing;\nSpO2 maintained 88-92%;\nPatient alert and oriented;\nNo cyanosis observed'
      ],
      [
        'Activity Intolerance R/T imbalance between O2 supply and demand AEB dyspnea on exertion and fatigue',
        'Patient will:\n- Perform ADLs with minimum dyspnea\n- Demonstrate energy conservation techniques\n- HR/RR returns to baseline within 3 min of activity\n  within 3-5 days',
        '1. Assess activity tolerance using Borg dyspnea scale before and after activity\n2. Plan care to allow rest periods between activities\n3. Encourage gradual increase in activity (bed → sitting → standing → walking)\n4. Teach energy conservation techniques: sit while bathing, use of assistive devices\n5. Schedule all activities (meals, hygiene) after bronchodilator use\n6. Teach diaphragmatic and pursed-lip breathing during exertion\n7. Refer to pulmonary rehabilitation program\n8. Ensure O2 supply maintained during activity; portable O2 if needed',
        '1. Identifies baseline and response to activity objectively\n2. Prevents overexertion and dyspnea episodes\n3. Gradual progression prevents deconditioning without overloading\n4. Reduces O2 demand; maximizes function within limits\n5. Bronchodilators maximize airway dilation before physical effort\n6. PLB increases positive end-expiratory pressure; reduces air trapping\n7. PR improves exercise capacity, QOL, and reduces re-hospitalizations\n8. Supplemental O2 during activity prevents desaturation',
        'Patient performs self-care with reduced dyspnea;\nHR/RR returns to baseline within 3 min;\nDemonstrates energy conservation techniques;\nProgress toward pulmonary rehab goals'
      ],
    ],
    [1600, 1600, 2200, 2000, 1600]
  ),
  spacer(),

  heading2('D. Key Nursing Interventions'),

  heading3('i. Independent Nursing Interventions'),
  bullet('Monitor vital signs (especially RR, SpO2, HR) every 2-4 hours'),
  bullet('Position patient in Fowler\'s or semi-Fowler\'s position to ease breathing'),
  bullet('Encourage deep breathing exercises and effective coughing every 2 hours'),
  bullet('Teach pursed-lip breathing (PLB) to reduce air trapping and dyspnea'),
  bullet('Teach diaphragmatic breathing to strengthen respiratory muscles'),
  bullet('Monitor and record intake and output (I/O) – adequate hydration thins secretions'),
  bullet('Provide small, frequent, high-calorie meals (COPD increases caloric demand)'),
  bullet('Assess level of consciousness (LOC) – restlessness / confusion = hypoxia alert'),
  bullet('Maintain calm, quiet environment to reduce anxiety and O2 demand'),
  bullet('Educate patient on inhaler technique (correct use is essential for effectiveness)'),
  bullet('Encourage smoking cessation – most important modifiable intervention'),

  heading3('ii. Dependent Nursing Interventions (as per doctor\'s orders)'),
  bullet('Administer prescribed O2 therapy via Venturi mask at ordered flow rate'),
  bullet('Administer bronchodilators via nebulizer or MDI (Salbutamol, Ipratropium)'),
  bullet('Administer IV/oral corticosteroids during acute exacerbations'),
  bullet('Administer antibiotics as prescribed (Amoxicillin, Azithromycin, Doxycycline)'),
  bullet('Prepare and assist with ABG sampling – monitor results and report'),
  bullet('Prepare patient for spirometry, chest X-ray, ECG as ordered'),
  bullet('Assist with NIV/BiPAP setup and monitoring as ordered'),
  bullet('Administer IV fluids if oral intake is inadequate'),

  heading3('iii. Collaborative Nursing Interventions'),
  bullet('Coordinate with respiratory therapist for pulmonary rehabilitation and nebulization'),
  bullet('Consult physiotherapist for chest physiotherapy (CPT) and postural drainage'),
  bullet('Refer to dietitian for high-calorie, high-protein diet planning'),
  bullet('Consult with physician for medication review and stepwise GOLD-based therapy'),
  bullet('Coordinate with social worker for home oxygen arrangement and financial assistance'),
  bullet('Refer to occupational therapist for energy conservation strategies'),
  bullet('Coordinate with palliative care for end-stage COPD (comfort and symptom control)'),
  spacer(),

  // ── 10. HEALTH EDUCATION ──────────────────────────────────────────────────
  heading1('10. HEALTH EDUCATION (Patient and Family)'),
  bullet('SMOKING CESSATION: Stop smoking immediately – it is the single most effective intervention to slow COPD progression. Nicotine replacement therapy (NRT) or varenicline may be prescribed.'),
  bullet('INHALER TECHNIQUE: Demonstrate correct use of MDI with spacer; DPI (Dry Powder Inhaler). Teach: shake – exhale – seal lips – inhale slowly – hold 10 sec – rinse mouth (after ICS).'),
  bullet('MEDICATIONS: Take medications exactly as prescribed; do not stop SABA without medical advice; carry rescue inhaler (Salbutamol) at all times.'),
  bullet('BREATHING EXERCISES: Practice pursed-lip breathing during exertion; diaphragmatic breathing 10 min twice daily to strengthen respiratory muscles.'),
  bullet('DIET: Eat small, frequent, high-calorie, high-protein meals; avoid gas-forming foods; eat slowly; avoid heavy meals before bedtime; stay hydrated (2-3 L/day unless restricted).'),
  bullet('ACTIVITY: Balance rest and activity; enroll in pulmonary rehabilitation if available; walk short distances daily and gradually increase.'),
  bullet('INFECTION PREVENTION: Get annual influenza vaccine; pneumococcal vaccine every 5 years; wash hands frequently; avoid crowded places during flu season.'),
  bullet('WARNING SIGNS to report immediately: Increased sputum (yellow/green = infection), severe breathlessness, chest pain, cyanosis, confusion, swollen ankles, fever > 38°C.'),
  bullet('FOLLOW-UP: Regular clinic visits every 3-6 months; spirometry yearly; keep all follow-up appointments; carry a COPD action plan card.'),
  spacer(),

  // ── 11. COMPLICATIONS ─────────────────────────────────────────────────────
  heading1('11. COMPLICATIONS'),
  numbered('Acute Exacerbation of COPD (AECOPD) – sudden worsening of symptoms (most common complication)'),
  numbered('Respiratory failure – Hypoxemic (Type 1) or Hypercapnic (Type 2)'),
  numbered('Cor Pulmonale – Right ventricular hypertrophy/failure due to pulmonary hypertension'),
  numbered('Pneumonia – Bacterial infection on background of damaged airways'),
  numbered('Pneumothorax – Rupture of bullae causing collapsed lung'),
  numbered('Pulmonary Hypertension – Increased pressure in pulmonary circulation'),
  numbered('Polycythemia – Elevated RBC count due to chronic hypoxia'),
  numbered('Cardiac arrhythmias – From hypoxia, hypercapnia, electrolyte imbalance'),
  numbered('Anxiety and Depression – Common in chronic breathless patients'),
  numbered('Malnutrition and Muscle Wasting – Increased metabolic demand + reduced appetite'),
  numbered('Sleep apnea overlap syndrome (COPD + OSA)'),
  spacer(),

  // ── 12. PREVENTION ────────────────────────────────────────────────────────
  heading1('12. PREVENTION'),

  heading2('A. Primary Prevention (Prevent COPD from occurring)'),
  bullet('Strict tobacco control – ban smoking in public places, tobacco taxation'),
  bullet('Smoking cessation campaigns and counseling'),
  bullet('Reduce indoor air pollution – use LPG instead of biomass fuel; improve ventilation'),
  bullet('Reduce occupational hazards – use N95 masks, enforce workplace safety standards'),
  bullet('Control outdoor air pollution'),
  bullet('Healthy diet and adequate nutrition during childhood for proper lung development'),

  heading2('B. Secondary Prevention (Early detection and treatment)'),
  bullet('Routine spirometry screening for smokers > 40 years of age'),
  bullet('Early diagnosis using GOLD staging criteria'),
  bullet('Regular health check-ups for high-risk individuals'),
  bullet('Alpha-1 antitrypsin testing in young patients with emphysema'),
  bullet('Influenza and pneumococcal vaccination for at-risk groups'),

  heading2('C. Tertiary Prevention (Prevent disability and complications)'),
  bullet('Pulmonary rehabilitation programs – exercise training, education, breathing techniques'),
  bullet('Long-term oxygen therapy (LTOT) > 15 hr/day in severe hypoxemia'),
  bullet('Regular medication compliance – LAMA, LABA/ICS combinations as per GOLD guidelines'),
  bullet('Patient and family education about disease management and exacerbation action plans'),
  bullet('Palliative care and quality of life support in end-stage disease'),
  spacer(),

  // ── 13. CONCLUSION ────────────────────────────────────────────────────────
  heading1('13. CONCLUSION'),
  para('COPD is a serious, progressive, but largely preventable disease. Nurses play a central role in managing COPD patients through continuous assessment, timely interventions, medication administration, and patient education.'),
  para('Effective nursing management focuses on maintaining airway patency, correcting gas exchange abnormalities, managing dyspnea, and promoting self-care. Smoking cessation remains the most powerful intervention to slow disease progression.'),
  para('By using evidence-based care plans and collaborating with the multidisciplinary team, nurses can significantly reduce complications, prevent hospital readmissions, and improve quality of life for patients living with COPD.'),
  spacer(),

  // ── 14. REFERENCES ────────────────────────────────────────────────────────
  heading1('14. REFERENCES'),
  para('1.  Brunner, L. S., & Suddarth, D. S. (2022). Brunner & Suddarth\'s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer Health. (pp. 584-612)'),
  para('2.  Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2023). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier Mosby. (pp. 547-575)'),
  para('3.  World Health Organization. (2023). Chronic obstructive pulmonary disease (COPD). WHO Fact Sheet. Retrieved from https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)'),
  para('4.  Black, J. M., & Hawks, J. H. (2021). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (9th ed.). Elsevier Saunders. (pp. 1702-1745)'),
  para('5.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2023). Global Strategy for Prevention, Diagnosis and Management of COPD: 2023 Report. Retrieved from https://goldcopd.org'),
  para('6.  Katzung, B. G. (2021). Basic and Clinical Pharmacology (15th ed.). McGraw-Hill. (pp. 565-568) [Treatment of COPD]'),
  spacer(),
];

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cd /home/daytona/workspace/copd-assignment && node create_copd.js 2>&1

python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…

ls -lh /home/daytona/workspace/copd-assignment/Nursing_Management_of_COPD.docx &…